Prevention as a Cure
The exposure part of “exposure and response prevention,” as described in the previous section, is easy to understand: The patient is gradually exposed to the thing or situation that she fears. The “response prevention” part makes it interesting: She is then encouraged to refrain from the usual things she does to make her worrisome situation tolerable. Simply put, with ERP you get exposed to your obsession and prevented from performing your compulsion.
Along the way, of course, you also learn techniques to help you tolerate the anxiety. This is the paradox on which ERP is based: People who have OCD often go to extreme lengths to avoid their feared object or situation in an effort to prevent the anxiety associated with it. The idea of exposure and response prevention is that it's necessary to experience anxiety in order to eventually get rid of it. Anxiety cannot accelerate forever. (Although you may at times doubt that!)
CBT can rarely be accomplished without some initial discomfort. Work through it! If you can stand up to your anxiety with the support of a therapist, a great reward may await you: freedom from your OC fears and the limitations they impose.
Let's say you feel terrible dread whenever you find yourself in the vicinity of a cemetery. Every time you pass one, you feel your whole body tense up and you become overwhelmed with a desperate longing to flee. You hold your breath for fear that evil spirits might enter your body, or, worse, that some terrible thing will happen to you or to someone you care about.
A cognitive behavioral therapist might encourage you and help you prepare to take a brisk walk just inside a cemetery gate. She might even accompany you. Instead of holding your breath and running past the area, as you usually do, you would be encouraged to try standing in place and breathing deeply for several long moments, then calmly walking away. You might be encouraged to repeat an affirmation to yourself, something like, “I am perfectly calm. I feel comfortable wherever I am.”
Later on, you'd try again, this time venturing farther inside and staying for a longer period of time. (Again, you might have to start by just standing outside, and then make your way past the gate on subsequent visits.) After getting enough practice, you would ideally be able to take on the task without undue anxiety.
An Exercise in Restraint
A clearer example of response prevention can be seen in patients who have contamination phobias. After contact with the feared object or situation (shaking hands, say, or touching a doorknob), the subject is asked to refrain for a period of time from washing his hands. At first, this usually causes significant distress, but with time, the amount of discomfort diminishes, perhaps even entirely.
In most cases, your cognitive behavioral therapist will assign “homework exercises” for you to do on your own, and you'll report back about your progress or challenges. In addition, you might also learn relaxation techniques to help you tolerate the feelings your feared situation may elicit.
The patient has the experience, usually repeated, of seeing his anxiety peak — but then subside! Soon enough, he often finds, he is able to shake hands or use doorknobs without fear, perhaps without even a second thought.
Whether ERP sounds doable or difficult will depend on your particular fear, how long you've had it, and how much you believe your compulsive “response” helps you to avoid danger to yourself or the people you care about. (This is where cognitive therapy comes in, helping you learn to assess the degree of real, versus perceived, danger.)